288.2 🩺 國考版

288.2.1 高頻考點

288.2.1.1 ASD

  • Secundum 70% > primum 15-20% > sinus venosus 5-10% > coronary sinus < 1%
  • Fixed split S2 (pathognomonic)
  • ECG: RAD + incomplete RBBB (secundum); LAD + first-degree AVB (primum)
  • Percutaneous closure for secundum; surgical for primum, sinus venosus, CS
  • Close if hemodynamic significance, paradoxical embolism, PH (not Eisenmenger)

288.2.1.2 VSD

  • Perimembranous 80% most common
  • 75% of small VSDs close spontaneously by 10 yo
  • Holosystolic at LLSB
  • Close if: significant shunt, LV volume overload, AR, prior IE, early PH (not Eisenmenger)
  • Surgical patch standard; transcatheter for muscular

288.2.1.3 PDA

  • Continuous “machinery” murmur below L clavicle
  • Differential cyanosis if Eisenmenger PDA (cyanotic feet, pink arms)
  • Treatment: percutaneous coil (first-line) or surgical ligation
  • Indomethacin / ibuprofen in premature infants

288.2.1.4 PFO Closure for Cryptogenic Stroke

  • CLOSE, RESPECT (extended), DEFENSE-PFO: closure + antiplatelet > antiplatelet alone
  • Age < 60 (selected 60-65)
  • Cryptogenic stroke, no other source
  • Atrial septal aneurysm or large shunt favors closure
  • RoPE score to assess attribution

288.2.1.5 AVSD

  • Strong association with Down syndrome
  • Partial (primum ASD + cleft MV) vs complete (large VSD + common AV valve)
  • Adult issues: MR, arrhythmia, HF

288.2.2 易混淆比范

Shunt Murmur ECG Closure Method
ASD secundum Fixed split S2 + SEM + diastolic rumble RAD, incomplete RBBB Percutaneous device
ASD primum Same + MR (cleft) LAD, AVB Surgical
VSD perimembranous Holosystolic LLSB Variable Surgical
PDA Continuous “machinery” murmur Variable Percutaneous coil
PFO Usually none Normal Percutaneous device (CLOSE)
AVSD Holosystolic + MR LAD, AVB Surgical

288.2.3 Special Topics

288.2.3.1 Eisenmenger Specific to Lesions

  • ASD: ~ 10% of unrepaired → Eisenmenger
  • VSD: 50% of unrepaired large → Eisenmenger
  • PDA: 50% of unrepaired large → Eisenmenger
  • Truncus / TGA / single ventricle: even higher

288.2.3.2 Endocarditis Risk

  • High in unrepaired VSD (subaortic), PDA, complex CHD
  • Prophylaxis as per 2017/2024 ACC/AHA